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For better quality measurement, engage patients in their care


We must give clinicians the tools they need to help patients become more active participants in their care.

Hilary Hatch, Ph.D.: ©Phreesia

Hilary Hatch, Ph.D.: ©Phreesia

Decades into the movement toward better health care quality measurement, no one is satisfied with the results. Clinicians are burned out from too many reporting requirements. They feel forced to tick boxes and practice toward the quality metric, not toward better medicine. Patients don’t see a meaningful difference in their care. The number of measures clinicians can report keeps growing, but the patient experience and health outcomes are not dramatically improving. Everyone is in agreement that this must change: the Centers for Medicare and Medicaid Services (CMS) announced the Universal Foundation of measures last year to focus on measures that would make quality reporting easier and advance equity, but there is still work to be done.

We designed these measures on the assumption that if we incentivize clinicians to focus on a particular outcome then the patient’s health will subsequently improve — whether that’s an a1c level or a blood pressure reading. But that’s not how it works. Patients play a huge role in filling a prescription, taking it as prescribed and monitoring their blood levels. Then there are the health-related social needs, like access to food, housing, and transportation, that all have an impact on health and are beyond the clinician’s purview.

Our quality measurement system largely ignores the role of the patient, and we cannot fix it without changing our paradigm. We must give clinicians the tools they need to help patients become more active participants in their care.

Why? Because engaged patients aren’t just nice to have. Without them, our system aimed at improving patient health can’t work effectively. But being a patient is a learned skill, and we shouldn’t take for granted that everyone knows how to do it. Very few people do, and that’s not their fault.

In some conditions, it’s more obvious that patients need training to do their part. Many patients with diabetes, for example, quickly become experts in how to monitor and manage their blood sugar because they may need to take injections multiple times a day. If they don’t, they face some immediate and severe physical health problems. But many other chronic conditions are silent killers like kidney disease and high blood pressure that worsen for months, if not years, before the patient realizes they need to respond. For patients with health-related social needs, the job of navigating our health care system is even harder.

What if clinicians had a system to assess patients’ ability to self-manage their health and could use that information to develop a care plan with the highest likelihood of success?

This is where I have good news: we already have such a tool, and it’s called the Patient Activation Measure, or PAM. The PAM is a brief survey that measures a patient’s knowledge, skills and confidence to self-manage their own health.

The PAM is already in use in quality programs, including the CMS Innovation Center’s Kidney Care Choices program. It’s also in the Merit-Based Incentive Payment System (MIPS), as well as in 18 specialty-specific measure sets and five MIPS Value Pathways (MVPs), which are subsets of measures for specific conditions. The PAM is a performance measure designed by experts and informed by more than 800 peer-reviewed studies. What we know from that research is that patients who are higher-activated are more effective at self-managing their health across conditions and more likely to be on track with preventive care. As patients take on a more active role in their care and their PAM scores increase, outcomes improve, and costs decrease. Activated patients also report greater satisfaction with their care.

Here’s how it works: The PAM approach sorts patients into four levels, from those who need more support to engage in their care journey to those who are proactive about their care. In this way, it offers clinicians a way to design a more tailored approach to treatment because it helps them meet each patient where they are rather than offering a one-size-fits-all plan. The PAM approach recognizes that different patients need different investments in time and training to become better at the job of being a patient.

My background and training is in clinical psychology, and there’s a simple rule that psychologists learn early on: your patients often aren’t equipped to follow what seems like good advice. If managing their mental health was so easy, they wouldn’t need to be in your office. It’s true beyond mental health, and most seasoned clinicians learn this over time, but don’t always have the tools and training to understand the patient’s abilities and support them. As a provider, once you understand each patient’s abilities, you can support them in becoming more effective managers of their own health. Patients will see how much you value and invest in their role as patients.

As our system increases its focus on equity, clinicians also need ways to assess each patient’s unique needs. With limited time invested, PAM helps clinicians identify the patients who need extra support.

The American Academy of Family Physicians said that our system of quality measurement needs three things: measures for outcomes, measures that reflect the continuity of care, and measures that look at the whole person. The PAM gives us the tool for all three, and it takes our quality measurement movement further down the path of patient engagement, activation, and empowerment. This should be our focus for the next two decades of the quality measurement movement, and the time to start is now.

Hilary Hatch, Ph.D., is the Chief Clinical Officer at Phreesia and a member of the National Quality Foundation’s Leadership Consortium.

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